The High Incidence of Post Intensive Care Unit (ICU) Anxiety and Depression

Many patients who are discharged from the Intensive Care Unit (ICU) frequently suffer health problems long after they've left the hospital. The patient and their loved ones are often puzzled as to why, having survived a critical illness, that the former ICU patient is unable to work, enjoy activities, gain weight, and/or regain happiness after leaving the hospital. In researching this topic, I was alarmed at the number of individuals who are plagued by a profound range of serious mental health issues coupled with prolonged physical weakness.

The purpose of this piece is to bring attention to the widespread incidence of post-ICU depression and mental health and to encourage education and networking of professionals interested in assisting post-ICU patients and their caregivers. Hopefully, information contained in the article will provide caregivers and loved ones of former ICU patients with practical suggestions on how to initiate a successful dialog with a variety of health care professionals and mental health providers to ensure that the post-ICU care received results in the best possible outcome.

More than five million Americans are admitted to hospital ICUs every year for treatment of critical illness, and admission rates are on the rise. ICU survivors often require prolonged and costly rehabilitation for several weeks following discharge, and about half of these survivors are unable to return to work one year after hospitalization because of depression and post traumaticstress disorder (PTSD). The prevalence of these and other post-ICU mental health challenges requiring therapy has increased substantially. Anxiety disorder occurs in 12 percent to 43 percent of former ICU patients, and levels of depression range from 10 percent to 30 percent. Most significantly, there is an astonishingly high rate of PTSD, as high as 64 percent in those who survive the ICU. Psychological symptoms frequently appear a short time after ICU stay and may decrease as time passes, however, some patients experience an escalation of depression, anxiety, and other mental health issues during rehabilitation. Symptoms may appear and extend months after discharge, and persistent, untreated post-ICU depression can impair recovery and quality of life.

Although post-ICU mental health conditions are becoming increasingly recognized by critical care practitioners, caregivers and/or mental health professionals often remain unaware of the profound effect ICU stays have on mental hygiene. Former ICU patients often experience personality changes, anger, sleep problems, and sadness. Frequently, these alterations are attributed to the patient's frustration with recovery, rehabilitation, and the progress towards getting "life back to normal." However, these changes are more commonly linked to the critical illness episode itself and the necessary care delivered during the ICU stay.

Pain, critical illness, infection, mechanical ventilation support for respiratory failure, medications, muscle wasting, and metabolic changes can contribute to post-ICU depression, PTSD, and anxiety. People with a prior history of mental health issues including depression, anxiety disorders, and PTSD may be more susceptible to developing psychiatric issues that require attention long after their ICU stay. A common culprit of post ICU PTSD and anxiety is the routine use of sedatives. Most critically ill patients receive sedatives and some, especially benzodiazepines, are more likely to cause disorientation, confusion, and even psychotic experiences. Often these sedative-induced hallucinations are perceived by the patient as real, and the recollection of these frightening and traumatic incidents can trigger extreme anxiety days or even months after leaving the ICU. Because the duration from ICU discharge to psychological symptom onset may be significant, patients, caregivers, and health care practitioners may not make the link between the ICU stay and mental health. This can result in a delay of treatment. Symptoms such as nightmares, sleep disturbances, avoidance, depression, and anxiety should be considered as possible signs of post-ICU emotional distress, and consultation with a qualified mental health practitioner is encouraged.

Psychological symptoms may occur in both the patient and family members who care for them. Caregivers, loved ones, and family members are not immune to post-ICU emotional hardship. Profound lifestyle disruption coupled with feelings of helplessness, stress, guilt, and depression are common emotions experienced by those caring for patients recovering from life-threatening infirmities. Interventions designed to help families cope with the burden of critical illness after they leave the hospital are being supported by many in the critical care community. ICU practitioners often encourage patients and their families to seek a consultation with a clinical psychiatrist or psychologist before ICU discharge and throughout the recovery and rehabilitation period. However, finding a licensed mental health professional that specializes in, or is familiar with, post-ICU depression can be challenging. Further, few, if any patient education materials exist to help guide the patient and their loved ones through the often stressful and emotional aspects of post-ICU care. A multidisciplinary approach to education and treatment, including cooperation between physicians, caregivers, mental health professionals, pharmacists, and dietitians, is paramount to improving mental health and physical status of former ICU patients and their families.

In addition to psychological symptoms, the post-ICU patient is often plagued by extreme muscle weakness that persists even a year after hospital discharge. Muscle wasting occurs despite adequate diet and the reasons are unknown. However, the long-term effects on quality of life are significant. Fatigue, lack of endurance, poor appetite, and depression often prevent the former ICU patient from being able to work or enjoy activities. Further, poor nutritional status can lead to other complications like impaired wound healing, falls and fractures, and other health issues that many times lead to re-admission to the hospital.

Recognition and treatment of post-ICU health issues remains limited at best. Many health care practitioners, former patients, and their loved ones are unaware of the long-term ramifications of surviving critical illness. Rehabilitation often addresses concerns of the physical body, but few post-ICU rehab programs address the mental health and nutritional aspects. If you recognize these symptoms in someone who has been in the ICU recently, contact your health care practitioner and discuss what can be done to improve their quality of life.

The author has worked in the critical field for more than 15 years and has first-hand experience with post-ICU patients suffering from depression and profound physical weakness.

I wholeheartedly agree that a long hospital stay, especially in ICU, can leave a patient depressed and suffering from many mental health issues including anxiety, lethargy, lack of appetite and the inability to readjust to normal life. As you so rightly say, this problem seems to be completely overlooked.
My late partner spent over 4 months in a surgical ward following a very severe attack of acute pancreatitis. His after-care on leaving hospital was abysmal. The British NHS appears unaware of the problem and makes no provision for long-term hospital patients to be monitored. I felt my partner was abandoned after being discharged from hospital and it was up to us to initiate all further care. When he was given treatment for depression,it was limited, inappropriate and his medication was inadequate. I believe that his mental state was a significant factor in his failure to recover. He died 7 months after leaving hospital and after being readmitted and then being in ICU.
What can be done to avoid this happening to others?

My son age 40 spent 6 weeks in ICU with pancreatitis. At one point he was given a 50/50 chance for survival. He, just last week was released. He is depressed. He cannot get over the fact he nearly died. So far no health care professional has followed up with him in regards to his depression. I have talked to my daughter-in-law re getting special help for him. I realize these individuals must have experience in dealing with persons who have suffered. There appears to be little studies done on this. Patients do survive now with modern medicine available to them. Yet, they need further follow up to assist the mental state as well.

I spent 3 months in hospital suffering life threatening infections in my heart. Numerous surgeries and fears of dying hung over me but I coped really well but a few weeks after discharge and initial elation I have sunk into a really bad depression, and get upset when I think back. There was no support or warning this could happen. Normal life is difficult due to fatigue and cognitive difficulties. I can't believe its so hard and isolating. Why is help not available or offered after suffering the initial critical illness?

I spent two months in the hospital as the result of an infection that caused my kidneys to fail and my lungs to collapse. I was put on a respirator and dialysis with less than a 2% chance of recovering. It's been about 18 months since I was released from the hospital and there are days that I feel extremely depressed and confused. I was in delirium most of the time and trapped in a bad dream that went on for about a month. I really don't know what the answer is and I totally understand how you feel. I think sometimes it's good just to share your story with others who have gone through a similar experience and let them know they're not alone.

I went in for a partial knee replacement and 4 weeks later woke up in ICU wondering what happened, where I was, what year it was, etc. On the 2nd day after knee surgery my lungs started bleeding which set into Ards, Sepis, and kidney failure. My family was called in after I stopped breathing but somehow God said it wasn't my time and I lived though that. Now I am finding it very difficult to live with depression, anxiety, aches and pains and just overall health. What I find hard is that the people around see you as walking and think you are OK but the sad truth is you are not OK. There are a lot of things going through your mind always, the horrifying dreams, the various hospitals, my health, will I get sick again, depression, anxiety, etc. Even though an article was published about me online (google my name) I don't think people around me understand my condition. I hope that we can all learn and be a support group for each other. I wish each the best in life.